Outbreaks of infection, including diarrhoea and vomiting 

This guideline provides guidance on outbreaks of communicable infection at Great Ormond Street Hospital (GOSH).

This document should be read in conjunction with the Great Ormond Street Hospital 'Major Incident Plan' (see document library), which incorporates the deliberate release of biological agents. 

Further information can also be found at:

• Health Protection Agency (HPA)            

• The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance  

• Pandemic flu: a national framework for responding to an influenza pandemic (2007)

Definitions

An outbreak

An outbreak of a communicable disease is suspected of occurring when an epidemiologically linked group of patients, staff or visitors:

• develop symptoms associated with or thought to be associated with a communicable disease (eg pyrexia of unknown origin, rash, respiratory symptoms, diarrhoea/vomiting)

• or when an indistinguishable organism, associated with a communicable disease, is detected from them (eg Group A beta haemolytic streptococcus, MRSA or influenza A) 

A potential outbreak occurs when susceptible individuals are exposed, or are at risk of being exposed, to a potentially communicable disease.

Outbreak control covers both the prevention of potential outbreaks and detection and management of actual outbreaks.

Minor outbreak/incident

A minor outbreak/incident is when the Infection Prevention and Control (IPC) team can deal with the incident using their existing resources, drawing on individuals within the Trust and laboratory services as routinely available, and not disrupting the function of the hospital significantly.

The following infection control advice sheets on dealing with cases of communicable/infectious diseases are available on the GOSH Intranet infection control webpage:

• clostridium difficile

• human metapneumovirus

• influenza A and B

• meningococcal infections

• parainfluenza

• pertussis (whooping cough)

• respiratory syncytial virus

• varicella (chickenpox)

• viral gastroenteritis (including norovirus)

An Outbreak Control Group (OCG) may form to co-ordinate actions. Minor outbreaks may involve critical incidents which should be reported to the HPA and North London Cluster (NCL) accordingly.

Major outbreak

A major outbreak is where action requires resources greater than are routinely available to the IPC team, where action is likely to seriously disrupt the running of the hospital or where the outbreak has serious consequences outside the trust.

To manage a major outbreak an Outbreak Control Group (OCG) or Major Outbreak Control Group (MOCG) will be called to co-ordinate actions. This includes the Clinical Site Practitioner (CSP) who may invoke the Trust Major Incident Plan.

The IPC team is responsible for informing as appropriate:

• Clinical Unit Chairs/Heads of Nursing/Lead Nurses

• Occupational Health department

• Quality, Safety and Transformation department through the incident reporting system

• Chief Operating Officer, Chief Nurse/associated Chief Nurse and Press Office  

• the Health Protection Unit or Health Protection Agency

• North Central London Cluster

Infection Prevention and Control (IPC) team

Detection and recognition of an outbreak/potential outbreak

The IPC team is responsible for the prevention, investigation, surveillance and control of infection in patients, staff and visitors to the Trust. As such they undertake continuous surveillance for potential outbreaks through various sources:

• All potentially serious cases of communicable diseases must be reported to the appropriate member of the IPC team during normal hours and the Clinical Site Practitioner (CSP) and covering microbiologist/infectious disease consultant out of hours.

• The IPC team will make an initial assessment of all incidents.

• A named person from the IPC team who will take the infection control lead on any incident – initially the Lead Nurse/Deputy Lead Nurse IPC or Infection Control Doctor.

Surveillance information notified to the IPC team

'Alert' signs and symptoms of communicable diseases

There are a wide range of communicable diseases which present in various ways but personnel should be alerted to the following signs and symptoms:

• diarrhoea and vomiting 

• rashes

• pyrexia of unknown origin

• acute respiratory disease/severe sore throats

• contact with communicable diseases for which they are not immune

• abnormal number of or unusual presentation of surgical site infections

Reporting of communicable diseases occurring in patients

The unit ward sister, doctor or manager must report to the IPC team any patients with symptoms of a probable or possible communicable disease, or any patients who have been in contact with a communicable disease and are known not to be immune.

Reporting of communicable diseases occurring in staff

Staff must notify their manager of any illness and report to the Occupational Health department. The IPC team must be informed if symptoms are suspected to be part of an outbreak or likely to initiate one. Outside normal working hours they must report to the CSP, who will report to the microbiologist on call if necessary.

Reporting of communicable diseases occurring in parents/carers/visitors

Parents/carers and visitors must notify the ward sister/manager of any illness related to a communicable disease who will then report to the IPC team as above. They will be given instruction for further management.

Laboratory surveillance

The IPC team constantly review the laboratory results for evidence of cross infection or unusual or communicable infections.

External information

Members of the IPC team should continuously monitor and assess reports of communicable diseases reported through local, national and international sources, in particular from the Department of Health (DH) and Health Protection Agency (HPA).

Action by the IPC team

Immediate assessment

Once an outbreak is suspected the IPC team will take immediate steps to:

• investigate whether an outbreak is/has occurred

• establish an initial case definition

• assess severity

• initiate initial control measures

• decide on further action

Further action

If an outbreak has occurred the IPC team will:

• assess the severity and manage the situation itself

• convene a small Outbreak Control Group (OCG) or

• convene the Major Outbreak Control Group (MOCG)

If the outbreak extends beyond the hospital, the IPC team will contact the following:

The Health Protection Unit (HPU) 
Tel: 020 7811 7100
Fax: 020 7811 7756

Advice may be sought from the HPA Colindale. A 24-hour advisory service is available on tel: 020 8200 6868.

Outbreak Control Group (OCG)

• IPC team

• Consultant, Ward Sister/Charge Nurse, Lead Nurse and/or Head of Nursing of affected unit

• Clinical Site Practitioners

 Additional appropriate staff may be drawn from:

• Consultant - Communicable Diseases Control (HPU)

• Consultant and Senior Nurse from the Occupational Health department

• Bed Managers

• Catering Manager or Deputy - if associated with food or water

• Chief Dietician or Deputy - if associated with food or water

• Director of Estates or Deputy - if associated with water, air conditioning, sewage or environment

• Hospital Sterile and Disinfection Unit (HSDU) manager - if associated with sterilisation or disinfection

• Medical Director

• Clinical Unit Chair

• General Manager

• Chief Nurse/Deputy Chief Nurse and Director of Workforce Planning

• Chief Executive or Deputy

• Director of Operations

• GOSH Press Office

• Director of Human Resources or Deputy

Major Outbreak Control Group (MOCG)

A MOCG is convened by the Lead Nurse IP&C/Deputy Lead Nurse IP&C or the Infection Control Doctor. This includes the CSP who may invoke the Trust Major Incident Plan. The MOCG will include:

• Outbreak Control Group (OCG) plus: 

• Chief Executive or Deputy

• Consultant - Communicable Diseases Control (HPU)

• Head of Nursing/Lead Nurse of unit concerned

• Clinicians concerned

• Medical Director

• Chief Nurse/Deputy Chief Nurse and Director of Workforce Planning

• Consultant and Senior Nurse form Occupational Health department

• GOSH Press Office

• Other individuals as deemed necessary

Individuals who are unable to attend are expected to send a representative to the meetings.

Outbreak management

The appropriate team (IPC team, OCG or MOCG) will meet to discuss the outbreak and delegate responsibilities within the below areas, some of which are discussed further:

• microbiology/epidemiology

• organisation of patient clinical care - medical and nursing

• decisions on restricted hospital admissions or closure of ward(s)/unit(s)

• closure of hospital

• organisation of extra supplies and consumables

• organisation of catering

• organisation of staff

• publicity (eg press statement from Hospital and/or SHA and press handling by the HPA (Colindale), if appropriate)

• written information for staff, parents/carers and patients

• administrative and financial support

The IPC team will be responsible for minutes and action notes of all meetings.

Microbiology/epidemiology

The IPC team and Occupational Health department, in conjunction with HPU or Health Protection Agency Colindale as necessary, will organise the following:

• The case definition and necessary clinical information to be collected and recorded.

• Investigation of patients and staff - to be carried out locally.

• Investigation of food/water - to be referred to an ACAS accredited laboratory. This will be arranged by the Consultant Microbiologist in conjunction with HPU.

• Epidemiological investigations - to be carried out either locally or in conjunction with the HPU/HPA.

Clinical care

The IPC team, the clinical team and the administrative team (co-ordinating team) must ensure continuing clinical care of all patients:

Symptomatic patients

If deemed necessary, patients should be transferred to the Infectious Diseases Unit (IDU). Where the number of patients is large, the above team (in conjunction with relevant managers) will decide on the allocation of a further ward area for cohorting patients.  

A decision to isolate patients in cubicles on individual wards may be taken. Consideration will be given to the likely cause of the illness, its mode of transmission, the need for negative pressure isolation cubicles, extra personal protective equipment, appropriately immunised or immune staff, and the need to restrict visitors as appropriate.

Powered air respirators with hoods are available on Intensive Care Unit (ICU) and the IPC team will advise on their use. Personnel must be trained in their use.

Appropriate investigation to identify the cause of the illness and its treatment will be directed by the IPC team and clinical teams.

Isolation facilities

An updated list of isolation facilities in the hospital is maintained by the IPC team and available on the GOSH intranet infection control webpage.

Symptomatic staff

Symptomatic staff should be excluded from duty and leave the hospital. Only if advised by the IPC team should they report to the Occupational Health Department. Outside working hours staff must report to the CSP on duty, who can contact a member of the IPC team should further advice be required.

Symptomatic parents or visitors

Parents or visitors must report to the ward sister/charge nurse who will report to the incident co-ordinator (Lead Doctor or Lead Nurse or the IPC team), who will collect relevant clinical information and liaise with the IPC team. Investigation and treatment should preferably be co-ordinated through their GP, the HPU or as instructed.

Decision to close units/wards or restrict admissions

The decision to restrict admissions or close a ward for infection control purposes, is made by the IPC team in conjunction with the clinical team and/or the clinical site practitioners. This decision is based on:

• the organism involved and its actual or likely transmissibility

• risks to the patient population depending on age and diagnosis (e.g. neonates or immune-suppressed patients) 

• number of isolation facilities 

• the layout of the ward/unit (e.g. can patients be cohorted in a bay or side of ward)

• a 'Ward closed' notice can be printed from the GOSH intranet infection control webpage and should be placed on the ward/unit entrance doors to inform staff and visitors 

If a ward is closed, the GOSH 'Bed Management Policy' must be followed.

Decision to close hospital or disrupt major services

A MOCG would make such decisions or advise the MIP co-ordination team, which is likely to have been initiated by this stage.

Administrative and financial support

The IPC team will use current resources to investigate and control most minor outbreaks. Additional funding for major outbreak investigation and control will be arranged by members of the outbreak control groups.

Ongoing management and end of incident

The co-ordinating team will meet daily or as necessary, to review progress on the outbreak and control. They will keep the Director of Operations, Chief Nurse and Director of Workforce Planning, Chief Executive or Deputy, the Director of Estates, the Director of Facilities and the Press Office informed (if not attending the meetings).     

The IPC team (or OCG) will define the end of the outbreak.

Recommendation and report

The IPC team, in conjunction with relevant teams, will make recommendations for changes of practice determined by the evaluation of the outbreak.

A preliminary written report will be prepared within 48-72 hours and a final report within two weeks.

Document control information

Lead author(s)
Deirdre Malone, Lead Nurse in Infection Prevention and Control, Infection Control

Additional authors
John Hartley, Consultant Microbiologist, Infection Control
Barbara Brekle, Deputy Lead Nurse, Infection Control

Document owner
Deirdre Malone, Lead Nurse in Infection Prevention and Control, Infection Control

Approved by
Clinical Practice Committee

First introduced: 1 November 2003
Date approved: 3 January 2012
Review schedule: Two years
Next review: 3 January 2014
Document version: 2.0
Replaces version: 1.0